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Wednesday, December 25, 2013

Injury Rehabilitation: The Magical 80% Rule

80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden,or non weight bearing on crutches or Roll-A-Bout
20 to 40% from beginning to bear weight to off crutches (normally needs removable boot/cast)
40 to 60% Gradually feeling less pain with walking with or without boot
60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball
80% Passed the 30 minute hard walk test without set back, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity.

It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can be filled with reflares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation.

I hope this post explaining the magical 80% rule used by most in the rehabilitation world has been helpful. Do not wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely. Good luck!!

Tuesday, December 24, 2013

Foot Pain: Dilemma of Good vs Bad Pain

This is the Post all my athletes need to read.

For the athlete dealing with a painful situation, coming to a useful understanding of what is good and bad pain becomes crucial to speedy rehabilitation. Good pain is discomfort that is appropriate to work out through, or to feel afterwards. Bad pain is discomfort that must be stopped, the breeding ground for setbacks and flare-ups.

Varying pain thresholds in athletes can greatly complicate matters. Some athletes with a high pain threshold can train through a more serious injury believing that they are doing no harm, only to find that the injury has greatly worsened. In this case, their body’s own feedback mechanisms have let them down. Something in their head is yelling “No Pain, No Gain,” in probably several languages. They can participate at very high levels with pain, hoping that they can work through it. Sometimes they can, but many times they can not and the injury gets worse. Most of these athletes need the outside help of coaches and personal trainers, doctors and physical therapists, to help set some limits. Their own “self-preservation” mechanism is not working properly. Evolution to better body awareness can occur with good coaching. There is hope for this group.

For other athletes, including myself, with low pain thresholds, all pain is bad and can not be tolerated. This group may actually learn to accept some pain as okay, or good pain. They can also evolve.

Besides varying pain thresholds, there are many physiological reasons that the exact same injury can hurt a lot more for one athlete than another. The closer an injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt. If the injury is on the outside of your foot, and you walk/run on the outside of your foot, you will hurt more than another patient who walks/runs on the inside or the middle of their foot. The weaker the area is before you are injured, the more you will hurt after the injury since it will take longer to get the area strong. These factors are just a few.

Remember, injuries first heal and then double heal. Some bones like your metatarsals may get approximately twice as thick during the total healing process. This is why tendon and ligament injuries can heal with scar tissue that leaves the tissue twice as thick. So, even when an injury is completely healed, more healing may occur for several more months possibly producing noticeable symptoms to the athlete. Healing always produces some level of pain with swelling, muscle tightness for protection, scar tissue breakdown, etc. This can be good pain. So, how do we make some sense with this?

4 Golden Foot Rules may give us some focus.

Golden Rule of Foot: Never push through pain that is sharp and produces limping.

Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen, aspirin, etc.

Golden Rule of Foot: 80% of healing occurs in 20% of the overall time, with the remaining 20% taking 80% of the total time.

Golden Rule of Foot: Good pain normally dwells in the 0 to 3 pain level (scale 0 to 10).

Let us focus on these 4 rules.
When an athlete asks if they can participate in their activity, there is no breaking of the rule of sharp pain and limping. Good pain may be at the start of a workout, then eases up. If the pain comes back in the middle of a workout, this is bad pain and it is best to stop. Participating with a team activity that is semi-dependent on you is tough as you ease yourself back into activity. But you must be clear from the start of the activity that you may need to stop if pain develops. Ask your co-participants to tell you if you are limping. Sometimes they see it before you feel it. Limping throws the entire body off, risking other injuries. Sharp pain normally produces limping, but limping can also occur as you transfer weight to avoid pain or if a body part is too stiff to bend properly.

Drugs, as simple as aspirin, ibuprofen, etc, can mask little to significant pain. Never take these drugs before participation, only after if allowed. In general, 6 hours before an event is permitted. Many of the anti-inflammatory drugs also inhibit bone healing, so are contra-indicated in bone injuries entirely.

Healing can take a long time to completely occur with any injury. The job of the doctor, therapist, and patient is to try not to repeatedly get in the way of the healing process. But even with our best efforts, we tend to take two steps forward, one back, then two forward, then three back, and so on. I am happy to say in following injuries for more years than most of my readers have existed on this earth, injuries do heal. People do forget what ankle they sprained in 2004, and what heel got plantar fasciitis in 2007. Yet, most healing occurs in 20% of the time, with the remaining 10-20% healing occurring in 80% of the time. When you are 80% better, level 1 or 2 pain still may exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, occasional flare-ups, to get rid of the last 20% of symptoms. It is considered the realm of good pain, but it can wear thin on our nerves and patience.

Good pain is pain/discomfort/soreness/tenderness/dolor that does not have to interfere with activity. Listen to your body. Does the pain cause limping? Is the pain sharp in intensity? Does the pain come on in the middle of an activity? Does the pain come on after an activity and hurt then for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 3 range, no matter what your pain threshold is. Good pain is normally gone the next day, so there are no residuals. Good pain does not cause limping, and is not sharp. Good pain, is not perfect, but your daily reminder to keep icing, stretching, strengthening, and listening to your body. Good pain can be a good guide to allow you to work an injury to complete healing.

But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more deconditioned you become, and the longer the return to activity process will actually take. So, it is better to try to discover the difference between good and bad pain. The better you become, the better decisions you will make in your athletic life, and the longer you will be an athlete. The better you become, the better prepared you will be for the next injury. An important medical decision may be made based on your knowledge of good and bad pain. If all pain is bad, you will have a less active life and may seek surgical intervention as a quick fix. If you still believe "No Pain, No Gain", I can not wait to see you at our sports medicine clinic as a regular customer. Learn about your body through this process. It has prevented 3 surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletics. Good Luck!!

Ball of the Foot Pain: Email Advice with MRI Images

This nice patient mailed me her CD from New Zealand. She is suffering from pain under and in the big toe joint from many years. This is my report to her.

Image of Tibial Sesamoid under the first metatarsal showing irregularities within the bone. The bone does not look totally healthy, but is not fractured or fragmented.

A slightly different image of the tibial sesamoid. The fibular sesamoid looked healthier. This can simply be from favoring her foot with some demineralization of the bone.

Here a large bursae or ganglion cyst is seen under the tibial sesamoid.  Sesamoid Fractures are often diagnosed when, in fact, the source of pain is in the soft tissue swelling under the sesamoid

Another image of the soft tissue swelling with some swelling in the tibial sesamoid (very slight).

Here we are at the joint level with our slice. The irregular white areas can be also seen below in the next image. This abnormal tissue arises from the plantar (bottom) medial side of the joint (arch side). This tissue, referred to as chronic synovitis, can get trapped in the joint and constantly irritated. Again, since it is on the tibial sesamoid side, it is often misdiagnosed.

Here the irregular soft tissue appears to be coming from the side of the joint. 

Another image of the same soft tissue swelling. When it arises from a joint, it is called a ganglion cyst. This may need surgery to remove the sac of tissue and tie off the stalk where it comes off the joint. 

Great image of this soft tissue mass causing so much problems.

These sacs can be injected with cortisone, not into the joint, to see if they will reduce. If not, they are removed.

Another side image of this mass.

From this view, and others, we know the cyst is filled with fluid. The problem with cortisone is not to inject other than the cyst which is quite small. If your doc feels uneasy about injecting, he/she may recommend surgical removal as a safer approach. Cortisone placed in the wrong spot can be dangerous.

Sunday, December 22, 2013

Sciatica and Piriformis Syndrome

Dear dr Blake,
    My name is Susan (name changed) I'm 33yrs old and suffer from piriformis syndrome. I was given your name by Dr Stephen Pribut, top sports podiatrist in Washington, DC. I have been injured for over 2 1/2 years now (in April it will be 3). I am in constant pain. I got injured as I was working as a nurses aid in a retirement home and I was helping a resident use the restroom. Well as he was standing there his knees gave out and he dropped and I jerked forward and twisted right. I immediately felt excruciating pain in my low back into my behind. Well about 8 months after I got hurt they finally did a second MRI and discovered my piriformis syndrome.
Dr Blake's comment: You will be able to see from the videos below what they saw in that MRI. What Dr Filler, neuro-surgeon, will say is that 25% of low back surgeries fail since they are actually piriformis syndrome in disguise. 

 I've tried everything from PT, pool, ice, heat, injections, chiropractic and finally surgery. Well my muscle is still tight and I still have immense pain and feel like I'm sitting on a rock. 
Dr Blake's comment: The importance of one of the below videos is that a percentage of piriformis syndrome patients have injured their SI joint (Sacro-Iliac) and the piriformis is in spasm to protect that joint. This could have easily happened in Susan's injury. 

Anyways I'm from Longview, Washington. Do you know anyone around here that specializes in this! My Dr is an Ortho surgeon and he has only done this maybe 4-5 times in his whole career! I'm desperate to have my life back! I'm even willing to travel I just need help!
Thank you for listening to me

Dr Blake's comment:

Hey Susan, I am so sorry. I would seek the advice of Dr Mark Reeves at the Virginia Mason Clinic in Seattle! This is a common problem and someone there should be familiar. Keep me in the loop and to speedy healing. Rich

Susan's Response: Thank you! I'm interested that you say it's common because I have been told it is an uncommon issue and most of the drs around here won't even take me as a patient because they don't know how to treat it and some have even said they've really never heard of it before! Lol so I hope dr reeves can take on my case and give me some relief! I need it! This pain is excruciating (hence the reason I've been awake since 3 and emailing you back so early!!) I'm just so ready for relief! And to be active again!! I appreciate your help and will definitely keep you updated!
Have a good morning
Dr Blake's comment: Perhaps a call to Dr Filler's Santa Monica office to see if they know someone in the Seattle area. All my Piriformis/SI joint issues see Dr Irene Minkowsky in San Francisco, so I am spoiled. She is a physiatrist specializing in that area. I would definitely have a non-surgeon tell you that you need more surgery. The videos below speak of some elements of rehabilitation, but as of now, there has to be a reason for your pain, and a common cure. 

After sending a note on her progress, Susan replied: 

Thank you. I talked to dr reeves and he referred me to a dr chun. I had another MRI done on Monday. And will get my results the 31st (10 days from now). You can share my story or whatever you would like to do. I was stuck in bed all week because of my pain. They taped my feet together so my hips would be in a certain way for the MRI and it was excruciating!! I couldn't walk by myself after that. I had one person on each side of me helping me. I just want to have my life back!! I can't do my normal life for the last 2 1/2 years! It would be nice to be active again! Anyways I'm trying to get into see dr chun I just need my referral and approval through labor and industries. :) I appreciate your help! 
Thank you 

Dr Blake's comment: So, I have a variety of very good videos below talking about so much of the syndrome. For Susan, Rehabilitation can not even start until we create a pain free environment. I am hopeful that Dr Chun can begin that process. The first stage of Injury Rehabilitation is Immobilization and Anti-Inflammatory. Susan is trying her best to Immobilize, but something is hindering her recovery. Since the piriformis is an external hip rotator in gait normally, which helps support the arch (preventing internal tibial and talar motion with pronation), as a podiatrist I will use a lot of highly corrected Inverted Orthotics to help this condition. If the problem lies in a jammed SI joint, the same orthotic can make the patient temporarily worse. Thus, the art of medicine. 

This is a good place to start a discussion on Sciatica and Piriformis Syndrome. Here are a few good videos discussing anatomy, diagnosis, and some elements of treatment. 

2 Balancing Videos to start slow and Gradually Get Stronger

Sunday, December 15, 2013

Hallux Limitus: Podiatrist vs Orthopedist

I was told I have hallux limitus over a year ago.  My podiatrist gave me a shot in my toe and that seem to help for awhile.  He said that I would need to have the joint replaced that after looking at my xray I am bone on bone.  Joint is shot.....not his words.  Anyway, I want to get a second opionion.  I have made an appointment with a good orthopedic for January.  Is this good to go see an ortho too.


Dr Blake's response:

     Both professions in general do a good job treating this ailment, but I suspect if you see 4 doctors (podiatrists or orthopedists) you will have 4 different approaches. This is definitely an injury that has its own artistic flare in treatment, and each doc is going to have a different approach. You want to find someone that is an artist as well as a technician. Since no one will make this joint normal again, and treatment typically is life long, find someone that does not necessarily have the "To Cut is To Cure" mentality. In this case, "To Cut is to Start Over" is more like it. You want someone who understands that the surgery should make the joint better for awhile, and that there will be management questions and concerns that come along constantly. I hope this makes sense. I have placed some of my other post links below on this topic. Dr Rich Blake

Pre-Dislocation Syndrome: Email Advice

Dear Dr. Blake,
I was diagnosed with pre-dislocation syndrome in my right foot 9 months ago. 
Dr Blake's comment: This normally refers to the 2nd metatarsal phalangeal joint where the toe begins to develop a hammertoe and begins to dislocate off its normal position on the metatarsal.

 I limited my activity, wore a flat post-op shoe for 3 weeks, and got custom orthotics.  Not only did the pain not get better, I developed sesamoidits in both feet, but worse in the right.
Dr Blake's comment: Pre dislocation syndrome of the 2nd MPJ is treated with metatarsal pads ( higher the better), budin splints when needed to control toe position or pain or both, icing 2 times per day, and metatarsal doming/arcing exercises. Orthotics are only for long term stabilization, not when the acute symptoms begin. If you have pain in the 2nd joint, every orthotic made will try to put weight on the first and off of the second. This weight transfer could be the reason for the sesamoid pain under the first metatarsal head (ball of the foot). 

Got orthotics adjusted.  Started icing and NSAIDS every day.  Right foot swelled up massive and was so tender I couldn't bear to have heavy covers over my feet at night or to put any pressure on the right foot. 
Dr Blake's comment: So, your initial injury now becomes a secondary war zone that must be calmed down. This acute phase must be turned into a subacute or chronic state with Immobilization. 

Okay, so then we tried 3 weeks on crutches (got marginally better, but still swollen and painful), 1 cortisone shot, 8 weeks with tall camwalker and a donut pad around sesamoid.  The latter resulted in 1 good day, 2 agonizing days, 1 good day, 3 agonizing days, 2 good days, 1 agonizing day, etc.  Still massively swollen and painful much of the time.
Dr Blake's comment: When the primary injury has such an acute phase, with swelling out of control, you must begin treatment of nerve hypersensitivity. A pain management specialist should be called into to help. The initial protocol is like the treatment for Complex Regional Pain Syndrome even if you have not been labelled as such. Also, non weight bearing on crutches typically does not get rid of swelling, since it is weight bearing that is needed to move the fluid out of the area. 

 X-rays do not suggest that it is fractured--just high arches.  I'm not running or hiking or anything else I used to do on a daily basis.  I can barely walk to the restroom without pain hence barely moving.  The next step might be a plaster cast all the way past my toes for a month or more.  I have a pretty demanding job and I'm not sure how I could do this and keep my job--they've already put up with a lot--so I am hesitant unless it is absolutely necessary.
Dr Blake's comment: In this scenario, immobilization in any form should be avoided. Even non-weight bearing on crutches makes the swelling worse, since weight bearing removes swelling if it can be done with little to no pain in a protected fashion. 

  Any advice on the whole idea of complete immobilization?  Could orthotics for the pre-dislocation syndrome have made me get sesamoiditis? I'm obviously now afraid of any more treatments since everything seems to have made it worse, although maybe that was just going to happen on its own, not sure.

Dr Blake's comment: Thank you again for emailing and I am sorry for your problem. These are the things I think you should be doing, but your doctors have the last say since they can see you. 

  1. Immediately begin to see a pain management specialist to help control the pain symptoms, and pervent this going forward towards CRPS. 
  2. Use the crutches with the cam walker and sesamoid pads to allow as much healthy weight bearing as tolerated. 
  3. Purchase some OTC Neuro-Eze online and massage into the tissues 3 times per day.
  4. See if your body can tolerate contrast bathing twice daily with the ratio of 1 hot to 1 cold water. 
  5. If the orthotics do not take enough pressure off the sesamoid, go back to have them redone for you will need this soon to help wean off of the boot. 
  6. See if you can find a flat hiking shoe (even if it is 1 size larger) that is stiff and limits the pain in the sesamoid area.
  7. Ask your PCP for an Rx now of Lidoderm Patches. 
  8. See my blog post on the CRPS checklist to look at all the areas to explore to get this under control. Good luck!!!

Saturday, December 14, 2013

Achilles Tendon Injury: Email Advice

Hi Dr. Blake,

I wanted to ask your opinion about which direction I should next take with my treatment.

I am a junior college lacrosse player. Last february (9 months ago now) during our preseason my achilles tendon was stepped on during practice. It hurt at the time, I had my trainers look at it but it didn't seem like anything serious so I did the usual treatment options, especially ice and anti-inflammatories. As the season went on, however, the pain got worse and worse. I saw our team doctor who said it was the sheath around my achilles that was inflamed, so he had my trainers place a heel lift in my shoes. But the pain didn't subside and by the end of the season I was placed in a walking boot for 3 weeks to calm the pain down.
Dr Blake's comment: Typically achilles tendinitis is an overuse injury, so your description of being stepped on makes it harder to get a read on. Putting yourself in the Immobilization Phase was the right idea, and it should be coupled with anti-inflammatory treatments as well. 

Over the summer I continued to work out but focus more on weights and cycling/swimming as running continued to be painful (although I did continue to run some). In addition, over the summer I began to do strengthening exercises.
Dr Blake's comment: This was the right order---Immobilize, Cross Train, and strengthen. You were beginning the ReStrengthening Phase of Rehabilitation. 

 When I came back to school in August I continued the strength exercises and lots of stretching but the pain didn't improve. We had a month long fall season and by the end of the month I was back in a walking boot as it was nearly impossible to walk because of the pain. 
Dr Blake's comment: The Immobilization Phase should take you to Pain Levels 0-2. I am not sure of your pain, but it sounds worse. You should stay in this Phase for 2 weeks longer than you think you need to. The restrengthening should continue, as well as the cross training as long as all of this can be maintained in that 0-2 pain scale level. If not, you are just fooling yourself that you are progressing. 

I had an MRI recently and our team doctor said that, while we had thought it was mostly achilles tendinitis, it appeared that while I did have some achilles tendinitis it was mostly bursitis that appears to be the issue.
Dr Blake's comment: Bursitis in front or behind the achilles is a common side effect of achilles tendinitis swelling, or the bursitis was the only source of pain from the beginning. Bursae are fluid filled sacs that collect fluid in the wrong place and act as an irritant to the surrounding tissue. Bursitis elsewhere is treated with cortisone shots, but these are risky close to the achilles. I prefer electrical stimulation with contrasts, or iontophoresis, while going to PT. 

 He checked by strength and noted that my left gluteus (it is the left achilles that is the problem) was weak. My trainers switched up my strengthening program to include more gluteus exercises to improve this.

At this point my doctor also prescribed a topical anti-inflammatory saying that if that didn't work we could consider doing a  cortisone shot into the bursa, but that after the shot I would be in a boot for a month as to avoid rupturing the tendon.

My question to you is that it has been a month and the topical anti-inflammatory doesn't seem to be doing anything (it hasn't helped with the pain or decreased the amount of swelling at all) would you recommend considering the cortisone shot as the next treatment option or do you think that custom orthotics might be able to provide some assistance? Clearly I would like to avoid the cortisone shot.
Dr Blake's comment: Definitely the shot is risky, but I like the idea of a boot for 1 month afterwards. I would not like to do a shot anytime soon. Consider an 8 day Prednisone Burst to reduce the bursitis, while you are doing iontophoresis in PT (transdermal cortisone).

Follow up the oral cortisone with voltaren or another NSAID with a good daily dose. Do Contrast Baths, the best way to reduce bursitis swelling, twice daily and remain in the removable boot for the next month. If you are not significantly better in one month, send me the MRI to look at because something will not make sense. Hope this helps. 

Thank you so much for you advice.
Dr Blake's comment: Tendinitis treatment follows the BRISS formula and The Good Pain vs Bad Pain formula. Memorize well. Good luck!!

Gretchen (name changed)

Thursday, December 5, 2013

Hallux Limitus/Rigidus: Email Advice

Hi Dr. Blake!  

Thank you for this wonderful blog!  I have been dealing with an injured (and re-injured) left MTP joint for years now.  It recently felt bad enough that I sought out my GP.  X-rays showed mild-moderate 1st MTP joint degenerative disease with joint space narrowing, subchondral sclerosis & cystic changes and osteophyte formation.  I tried googling all this, but would love it if you could explain these in lay person terms. 
Dr Blake's comment: You have arthritis in your big toe joint which is causing pain. Below are some links to Hallux Limitus/Rigidus which are degrees of restricted range of motion that develop as the arthritis worsens.

 I have a little range of motion loss compared to the other side, but I still think it's around 60 degrees.  Am I on the road to hallux limitus? 
Dr Blake's comment: Yes, and you need to daily do the self mobilization technique in my video below. Also, if you pronate, get orthotics for your most strenuous activities. Place dancer's pads in any shoes you can. 

 My main complaints are the pain and swelling that occur after walking around with  shoes with 1" or 1-1/2" heels as well as after tap dancing.  I am currently not tapping, but would love to return to it, but am worried about irritating the joint.  Lastly, I see you mentioning dancer's pads often.  Do you have instructions on how to craft one?  I appreciate any advice and help!
Here a dancer's pad to float the first metatarsal head is made of Spenco material and glued to the bottom of the shoe insole. 1/8th inch to 1/4th is normal, but you should never feel like you are falling into the hole created.

Here the 1/8th inch adhesive felt from is being used to change weight bearing off of the 5th metatarsal. 
Dr Blake's comment: You should do just fine with tap dancing with icing twice daily to reduce the inflammation, dancer's padding with 1/8th inch adhesive felt from, use of Hapad Longitudinal Medial Arch Pads for the shoes from You may also need to learn to spica tape. 
Here Small Longitudinal Medial Arch Pads from the Hapad company are used as an arch support to transfer weight from the big toe joint into the arch and also into the 2nd and 3rd metatarsals and off the big toe joint. Because it is an adhesive felt, it can be moved around and thinned by peeling when needed. 


Friday, November 29, 2013

Inverted Orthotic Technique: Rx Writing Flow Chart

Components needed in filling out a prescription for the Inverted Orthotic Technique

When ordering the Inverted Orthotic Technique for patients with moderate to severe pronation, or those patients needing specific varus canting, this drawing above can give you the components to think about. The 4 basics aspects are:
  1. Pouring Instructions
  2. Positive Cast Instructions
  3. Plastic Instructions
  4. Additional Instructions
Future blog posts will look closer into each of these aspects. 

Thursday, November 28, 2013

Varicose Vein Photo

Stretching: General Principles

Here are my 13 Stretching Tips for every muscle/tendon in the lower extremity (hips, knees, ankles, and feet). These general principles help to avoid injury and should be used daily. Proper stretching is vital to the health of our muscles.

•#1   Hold each stretch for 30(minimum) to 60 seconds, and repeat twice.

•#2    Alternate between sides while stretching (for example, right achilles with knee straight, then left achilles, then right, then left).

•#3    Do not bounce while stretching, hold steady.

•#4    Deep breathe to get oxygen into the muscles while stretching. Normally 5 deep breathes equals 30 seconds.

•#5    Stretching before exercise should be done after a light warm up, like walking or stationary bike or jog, and is crucial, and is crucial in preventing many injuries due to tightness like achilles or hamstring strains. Julie Cox, PT, recommends pre-activity stretching to be slightly less time (20 to 30 seconds) followed by gentle rhythmical motion to warm up the muscle group involved for another 30 seconds. For example, achilles stretching pre-workout could be followed by a gentle rhythmical motion for 30 seconds (back and forth) between raising the heel up off the ground and then lowering the heel back down. Stretching hard when the muscles are cold (based on weather or time of day) can injure the muscle and gives pre-workout stretching a bad name. I personally like 5 minutes of stationary bike or walking or a sport specific activity (shooting before a basketball game) before starting my pre-workout stretch.

•#6    Stretching after a work out is the most important time to gain flexibility since the muscles are heated up.

•#7    If one side of your body is tighter, do twice as many stretches on that side versus the looser side.

#8    If you want to gain flexibility, stretch the desired muscle group three times per day, whether you work out or not.

#9    If you want to maintain flexibility, average one time per day stretching the desired muscle group.

#10  Never stretch through pain, it only makes the muscle tighter afterwards.

#11  Make sure when stretching that your body is stable (not likely to fall over, etc)

#12   Most muscle/tendons can be stretched for better results in various positions. For example, when stretching the hamstring, you need to stretch both the upper and lower parts. And especially for the lower hamstring, you can stretch various parts by positioning your foot straight, externally rotated, and then internally rotated. You will feel the pull on the hamstring at different parts.

#13  With many muscle/tendon injuries, if you can find a way to stretch it which relaxes the sore area, you are going to heal much faster. As long as you can stretch without making it painful, you can stretch an injured muscle/tendon 5 to 10 times daily.

Wednesday, November 27, 2013

Positive Casts showing Forefoot Deformities needing different Orthotic Design

Podiatrists will start with a cast of the foot and some examination findings (both static and dynamic) to design complex foot inserts which change function and better patient's lives. It typically starts with an impression cast of the patient's foot. This image shows 3 left feet, all taken with the same cast technique, showing 3 different foot types. The cast on the right is fairly stable and neutral positioned. The middle cast shows a foot that easily rolls to the outside and needs stabilization for supination. This demonstrates forefoot valgus. The left side cast shows a foot that easily rolls inward producing over pronation. This is called forefoot varus, and there are various corrections for this based on degree of deformity. 

Forefoot Varus Orthotic Corrections: Based on Degrees of Deformity

Tuesday, November 26, 2013

Walk/Run Program for Injury Rehabilitation

The Walk/Run Program

Most sporting activities require some running. Running can be an excellent return to activity conditioner. After recovering from an injury, the athlete finds great physical and emotional strength from a gradual buildup of running. Injury rehabilitation can involve crutches, cast, surgery, and rest. At some point, when the athlete is back to walking 30 minutes, without pain, and without a limp, a Walk/Run program can be started.
The Walk/Run Program that I have used for many years uses a 30 minute time period, based after the more classic 30 minute hard walk test that qualifies the athlete to begin jogging. However, you can start the program based on a 20, 30, 40, or even 50 minute period. It all depends on what you want to get to. I have used the 30 minute program personally twice in my life, once after a back injury, and the other after a knee injury. I found the program difficult since I was out of shape for running, yet safe with its low start and gradual progression. It was not as easy as it looks when you have not run for awhile.

There are 10 levels:

Level 1     Walk 9 min Run 1 min Repeat 3 times for 30 mins
Level 2     Walk 8 min Run 2 min Repeat 3 times for 30 mins
Level 3     Walk 7 min Run 3 min Repeat 3 times for 30 mins
Level 4     Walk 6 min Run 4 min Repeat 3 times for 30 mins
Level 5     Walk 5 min Run 5 min Repeat 3 times for 30 mins
Level 6     Walk 4 min Run 6 min Repeat 3 times for 30 mins
Level 7     Walk 3 min Run 7 min Repeat 3 times for 30 mins
Level 8     Walk 2 min Run 8 min Repeat 3 times for 30 mins
Level 9     Walk 1 min Run 9 min Repeat 3 times for 30 mins
Level 10                    30 min Straight Running

Each level should be done 3 times minimum depending on how you feel. Each session should be followed by a rest day to see how you feel. Therefore, completing Level 1 should take a minimum of 6 days. For example, start Walk/Run on Monday, rest Tuesday, 2nd session Wednesday, rest Thursday, 3rd session Friday, rest Saturday, and ready to start Level 2 Sunday as long as Level 1 was fine.

Gradually work your way through all the 10 levels. Remember to stay pain free. If you pass to the next level, but your pain starts to come back, rest 3 days, and go back to the level you were comfortable at for 3 more sessions. Again try to get to the next level. If you again have troubles, stay for 6 sessions at the comfortable level continuing to run every other day. Most patients gradually go through the 10 levels in 2 months (60 days), but some have taken a lot longer to progress. Remember, if you listen to your body, not push through pain, you will make it very safely.

The Walk/Run Program works well with even minor injuries where there are questions of when to start running. If you have only been off running for a short time, but you feel anxious about starting running, try this program. In its quickest form, Level one first day, then a rest day, then level 2, then other rest day, and so on. As long as your symptoms are fine, and you do not push through pain, you can get through the 10 levels in 20 days. This is normally better than running 3 miles the first day, having a flare up of symptoms, then stopping running for 2 more weeks. It allows you to test the waters of running more safely.

Remember another Golden Rule of Foot: It is better to run 1 second than not at all. Patients ask me all the time if they can start running. If they can walk 30 minutes at a good pace, without pain, and without limping, then they can start running. Any running for most athletes is better than not running. If you can not do the 1 minute for Level 1 Walk/Run, try 10 to 30 seconds running telephone pole to telephone pole.

Getting back into running shape can be safe with a Walk/Run program. It may require some individualization, but you will go either at the speed you were meant to, or slightly slower. You will get there!! Good Luck.

Monday, November 25, 2013

Neural Flossing: Initial Lesson for patient with Ankle Nerve Pain

Podiatrists deal with a lot of nerve pain. Neural Flossing or Gliding is a great technique to be tried to gently move the nerve and prevent scar tissue and swelling to collect around the nerve. Here, this wonderful patient, agreed to have me video her initial exposure to Neural Flossing. The motion should be gentle and smooth. The patient should do 10 leg extensions and 10 leg flexions 3 times per day. For nerve pain in the foot and ankle, neutral spine is important. The patient should extend the hip, knee, and ankle with foot pointing, then immediately flex the ankle, knee, and hip. Comparing the two sides is a great way of seeing the differences, the starting point issues,  and the  progress made. This patient has a long way to go, but the lesson really showed us a lot of why she is still having problems with lower extremity stability.

Orthotic Modification: Easing the Transition from Plastic to Weight Bearing Surface

Post Sesamoid Removal Problems: Email Advice

Hi, Dr. Blake,

Your blog has been a WEALTH of knowledge for me this past year... I had a chronic foot injury that went undiagnosed (properly, at least) until March 2013. At that time, my expert ortho surgeon and I decided that my medial sesamoid would be removed, as it was fractured/fragmented. I also needed my bunion repaired and hammertoe (second toe) fused to allow a plantar plate tear to heal. The surgery took place in April 2013, and it is now Nov 2013.

 I have had MANY ups and downs since then. I've done everything I can to heal the right away--PT, acupuncture, swimming, orthotics, TENS machine, etc. I just had a follow-up visit last week, and I'm just disappointed with my progress... I seem to have "decent" and "bad" cycles of pain, and have been in a fairly bad one for the past few weeks. Prior to that, I thought I was turning a corner and started doing some more "challenging" activities like some light hikes in the woods and testing out some jumping activities, but always with orthotics on and atop thick Pilates mats! 
Dr Blake's comment: Flareups are very difficult to take during the 2 year rehabilitation course you are on, but you must get through them. Sounds like you are doing everything well. Do your orthotic devices protect the sesamoid area well? Develop a short Immobilization routine you do as soon as a flare strikes----typically removable boot and icing in some form. Remember, flareups are normal, normally not a sign of anything dangerous, and just means you misread what you thought you could do safely. I seem to be an expert at that scenario. 

I was doing great, I thought, but as of a couple of weeks ago, the remaining sesamoid region in the left foot started to bother me a bit. My ortho is quite positive it is NOT fractured--everything has healed VERY well on X-rays (screw in big toe is still in place and looks normal), but he said I could get a CT scan just to set my mind at ease... I'm not having a ton of swelling--I actually have not since surgery, but I DO have pain...
Dr Blake's comment: There is no indication of fracture, but the demineralization process from disuse can make the bones more sensitive. Motion of a still healing joint cause cause swelling in that joint. In the big toe joint, the swelling drapes over the sesamoids causing sesamoid pain when the sesamoids are fine. I hope these are part of your problem---fixed by walking, good diet, and icing/contrast bathing. 

 Part of my pain is related to my tendency to produce EXCESSIVE internal scar tissue when I've had a traumatic injury or surgery. When I fractured my right tibial plateau back in 1998, it took years to feel "normal" again, and I've had flare-ups. THIS is worse, though, as it's my forefoot and taking more pressure than even my knee! ;) At any rate, my ortho is very knowledgable about folks who are prone to excessive scarring (it's definitely genetic for me, though my scars LOOK fine externally!), but there's not much more he can do. My main fears right now are: 1) that I HAVE fractured the other sesamoid and 2) that I'll never feel less pain due to this excessive scarring... I really cannot bear it if I have to wear a CAM boot AGAIN for most of a year to see if yet another fracture will heal. I am praying it's just scarring/bruising/sesamoiditis, b/c at least I can "manage" that somehow... It's hard to know at this point what is "new" and what is just related to my body continuing to "rehab" from the surgery! I know I had rather extensive procedures done, but I guess I had hoped to be in a better place by nearly 8 months out. My doc said it could take my foot up to 2 years to calm down. Any suggestions at this point? Hoping to hear from him today re: ordering me a CT scan! I really don't want to have a totally sesamoid-less foot, but I can't really fathom going through my entire life worrying I've damaged the remaining little bone! ;) Help! Thanks in advance! 

Dr Blake's comment: First of all, you need to put yourself back in the Immobilization Phase with a Removable Boot with Accommodation, an EvenUp for the other side, and 3 times a day ice pack, until the symptoms of this flare calm down. For flareups, you really should be prepared to do this on a regular basis as soon as possible since it calms things down so much quicker. 
     Scar tissue maturation, when the external and internal scar thins out and gets in the way much less, always occurs from 9 months to a year. This will give you a better, less scarred, big toe joint, but will not even start until late Jan 2014 and end early May. You have over 2 months before that process begins, so I would be kind to your joint between now and May 2014. I would immobilize with flares, work on joint range of motion, work on foot strengthening, weight bear only with protection, increase your cardio (biking, swimming, etc) without jumping!!
     What has the PT said about your range of motion? How is your foot strength? How is your bone strength? You always get transient demineralization with casts making the other sesamoid and foot prone to stress fractures, so you must be getting your calcium and Vit D3 and know where you are at bone wise. 
     Get the CT scan and let me know what it says. Begin your own self mobilization as the video shows below. Have the PT measure you so we can have a starting point. This is very important if you are worried about internal scarring. 

Sunday, November 24, 2013

Tim's Place: A Wonderful Story

Toenail Fungus: Key Points of Treatment

Fungal toenails, or onychomycosis, can be unsightly and lead to ingrown toenails due to their increased thickness. In general, I like to stay away from medicine, oral anti-fungals, due to their liver side-effects. I try to stay in an environment-changing treatment arena. It can easily take up to a year to notice a considerable difference with any treatment, so many just leave it alone. For those of you willing to undertake the task of attacking this invader, here are your weapons.

What kills fungus? Air, vinegar, bleach, tea tree oil, and dryness are a few of the weapons we can easily combine to kill fungus. Fungus lives in the moist areas of our lives like shower stalls or shoe linings. Fungus lives in an anaerobic environment under the nail made more comfortable with fresh nail polish holding out the air.

One problem we have conquering toenail fungus is time. It takes over one year for the toenail to completely grow out twice. There is a general rule that it takes not one, but two of these growth spurts to push the unsightly debri of the killed fungus out from under the nail bed. Some smart person figured that out, but like anything else it is still a general rule with exceptions for longer and shorter time periods. So, we can successfully kill the fungus, but the nail still looks disfigured until all the debri is pushed out from under the toenail. Definitely, this is unfair!!

Let us again look at our weapons and how we will use them. They are:

1) AIR---get as much air under the nails by cutting the nails as short as possible monthly, gently cleaning the debri under the nails as long as there is no bleeding monthly, using an emery board weekly to file the top of the nails as thin as possible, and avoiding toe nail polish as much as possible (quickly remove when not needed).

2) VINEGAR---soak in white vinegar 30 minutes twice weekly using a 1 part warm water to 1 part white vinegar ratio (see another post on using gauze to create vinegar patches for nightly use especially for only 1 or 2 bad nails).

3) BLEACH---disinfect your shower weekly with bleach (for example, Lysol).

4) TEA TREE OIL---apply daily tea tree oil twenty minutes before you go to bed to each affected nail and surrounding soft tissue. It must dry well before getting under the sheets.

5) DRYNESS---air out your shoes weekly that you use regularly by removing the shoe inserts, applying foot powder under and on top of any insert, and rubbing at the top of the toe box where you imagine the toenails rub.

6) PATIENCE---you will need some of this to succeed, and you will!!

If you have very thick toenails when you are starting, ask a podiatrist about doing the Carmol 40 Urea Ointment occlusion treatment. This is discussed in another post, but is great at removing the nail without shots, and without bleeding. It is the bleeding that is bad in this process, because the blood is a candy store for the fungus. Many podiatrists recommend seeing them once every 1 or 2 months during the initial 6 months to thin the nails with their electrical grinders. It sounds gross, but it should not hurt at all. In fact, this whole process should be painless.

If you decide to use oral medicine, use pulsed Lamisil. It is the safest that I know where you take for only 7 days each month for 6 months. You still have to do the topical treatments as mentioned above. At present, the pulsed Lamisil does not need liver testing as part of the treatment, but your prescribing doctor may feel safer doing that. Golden Rule of Foot: Always error on the side of caution.

With the advent of Laser toe nail cleansing treatment, I would normally recommend this over oral medicines. If helps clean out the fungus debri faster than anything, but it is not a cure. 50% of patients think they were helped by it.

Sesamoid Pain: Primary or Secondary to Swelling

This MRI image of the ball of the foot highlights swelling under the first metatarsal produced by a joint sprain but causing palpable soreness on the sesamoid bones. The xrays showed a possible fracture of the tibial sesamoid and surgery was being considered. The MRI clearly shows that both sesamoids are fine (to the left and right of the arrow under the first metatarsal head). This patient actually sprained the 3rd metatarsal phalangeal joint (see the reactive swelling or whiteness) and was favoring that area placing weight abnormally on the big toe joint. 

Achilles Tendon Partial Tear MRI Images

This patient presented with a 9 month history of pain in the achilles tendon area. There was no incident of acute pain, however the pain did come on during a long run. The patient continued to finish the 10 mile run, but knew that the achilles was a problem. The MRI (now 9 months post injury) shows surrounding swelling (white regions) and over 50% of the body of the tendon showing changes. The achilles tendon should be solid black, if healthy, in this imaging like the less than 50% on the right side. Within the injured part of the tendon, while the healing goes on, the tendon is part swelling, part tendon, part scar tissue, part stuff that makes it take on an irregular appearance. It is 50% unhealthy. 

A different image of the above tendon which does not highlight swelling. In this image the tendon does not look as bad. This is a T1 image where the above is a T2 image. 

There the side view of a T2 image showing the body of the tendon looking unhealthy (you want solid black). 

Another side view of the achilles with T2 weighting showing the area of partial rupture and the healing process. The central area would look very white if this image was within 2 weeks of the actual injury.

A final side view through the more normal 50% of the tendon showing swelling in front of the tendon, a little tear within the tendon, but overall a very healthy part of the tendon. The swelling in front of the achilles is called a retrocalcaneal bursitis.